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LIVERPOOL NORTHERN HOSPITAL.
368
by pushing the intussusceptum out by pressure on ptoms of the condition were unusually well marked. Mr, the sheath, and partly by very gentle traction upon it. Puzey refers in his remarks to Mr. Rivington’s excellent It is very important that the parts should be well article on Orbital Aneurysms, and we find there mentioned in view when the swollen head of the tumour is being that in four traumatic cases, out of fourteen of which the returned, so that the amount of tension that is produced can post-mortem examination is given, there were arteriobe noted, and so that any laceration of the peritoneum, venous communications between the carotid and the cavershould it occur, may be detected and afterwards closed by nous sinus. Mr. Rivington refers to thirty-two cases of suture. I am convinced that in the majority of cases reduc- pulsating exophthalmos of traumatic origin, twenty-seven tion can be easily effected in the manner described, if the of which recovered and five died after ligature of the intussusception has not been strangulated for more than ten common carotid artery. " Of the twenty-seven patients or twelve hours ; but if strangulation has existed for eighteen who recovered after ligature, only seventeen were cured hours and upwards, reduction is likely to be difficult and of the aneurysmal affection of the orbit, additional will often be impossible. In the case above related the age methods being employed in the others. Ligature of the of the patient was nine months, and the intussusception common carotid is at present the most successful and satishad existed for about eighteen hours. In a successful case factory means of treating orbital aneurysm. The percentage which I recorded in 18753 the child was seven months old, of absolutely successful cases or cures would be about fiftyand the intussusception (which had apparently existed for five." We have recently referred to the high mortality met, fourteen days) had been strangulated for twelve hours. In with after ligature of the common carotid, and it is possibleboth, at the time the operation was performed, the infants that in this case the earlier compression of the vessel aided’ were in a condition of collapse ; the one was pale, his face in the efficient blood supply found after the application of was pinched, his pulse quick and feeble, and vomiting was the ligature. E. E-, aged thirty-seven, a farm labourer from North frequent; the other 6lay in his mother’s arms, vomiting every two or three minutes, with a pale shrunken face, Wales, was admitted into the hospital on May 2nd, 1889, half-closed eyes, a small and very rapid pulse, and shallow, and gave the following account of himself. He had always.
hurried respiration." Yet both recovered without a drawback of any kind, and were convalescent on the third day; both, that is to say, notwithstanding their serious condition, bore the operation perfectly well, and rallied immediately after it. In the case which I published in 1875 the operation was performed in a labourer’s cottage, with no antiseptic precautions. The intestines were for some minutes lying exposed outside the abdominal cavity, and the patient was subsequently nursed by its mother without skilled assistance. The facts observed in these two cases appear to constitute strong evidence that even young infants will bear the operation well. That failures have hitherto been frequent has been, I think, quite certainly due very largely to the circumstance that the operation has been delayed until the local conditions-swelling, inflammatory softening, and adhesions have precluded success. These conditions are not usually present in the first twelve or -
enjoyed good health until fourteen months ago, when he fell off a horse on to the left side of his head. He was semi. conscious for a day or two, the only thing he remembers) being that on the morning after the fall he noticed "anoiselike a steam-engine puffing in his head," just above his left, ear, and this has continued more or less ever since. Both eyes were swollen at that time, especially in the morning, the leftbeing the worse of the two. Four or five days after the accident he went to work, though the noise in his heacfj much troubled him. He was unable to see clearly unless he covered one eye. Six weeks after the accident he went. to the Liverpool Eye and Ear Infirmary, and remained thereunder the care of Mr. Edgar Browne. ]Jfr. Edgar Browne’s report.-E. E- was admitted on May 4th, 1888, his condition being as follows : Right eye: V. =t%, slightly myopic, with - 0-50 V. =’3!1, T. and appearance
normal; pupil active ; nystagmic
jerkings on
extreme
lateral deviation to either side; ophthalmoscope shows’ even the first eighteen hours. I ought, however, to mention shallow physiological pit. Left eye: V. =idem, slight, that in a case, under the care of Mr. Gay of Putney, in proptosis ; movements in all directions limited, pupil active, which I performed abdominal section about fifteen hours but rather le3s so than the other. Conjunctiva injected, (so far as could be ascertained) after the occurrence of the very large, tortuous, episcleral veins at the outer side; aful3 intussusception, the volvulus had become universally adhe- cushiony feeling on pressing eyelids. Pulsation of eyerent to its sheath, so that although the parts were well in ball distinctly felt on pressure. Ophthalmoscope showsview, and no inflammatory softening and only very limited marked physiological pit, with vessels crowded to one side,
swelling
were
present, it
was
impossible
to
accomplish
reduction. The possibility of this rapid formation of adhesions is an additional reason for early interference. I have lately examined the specimens in the museum of St. Bartholomew’s Hospital, with the view of ascertaining whether, when it is found that the head of the intussuseeption is so large and firm that it cannot be returned, it would i be possible with safety to divide the sheath at the seat of constriction, and then, having effected reduction, to close the wound in the sheath by suture. The point, however, is one which I think can only be determined by trials made in what may seem to be appropriate cases at the time of operation. Other cases in which abdominal section for intussusception in young infants has been successfully performed have, I believe, recently occurred. Their publication, I may perhaps be allowed to say, would be a valuable contribution to this important subject.
as in a glaucomatous disc, with pale halo, no pulsation of arteries could be produced even by firm pressure. There is a loud aneurysmal bruit on the left side of the head, loudest in the temporo-parietal region, immediately over the left ear, and extending forwards ; the sound becomes. fainter on approaching the vertex, again increasing towards the lower parietal region of the right side. It is stopped entirelv by moderate pressure on the left carotid. Diplopia. is marked, being due to the left eye, which is unable ta.
conjugate movements with its fellow, in consequence of orbital swelling. No implication of any motor or sensory nerve was observed, mental faculties unaffected. The diagnosis of intra. cranial aneurysm was made, and the treatment was-rest, full doses of iodide of potas sium, low diet, fluid restricted to one pint per diem, and digital pressure on the carotid. Steady improvement went, on for some weeks, interrupted once by the patient rising. Great relief from the noise resulted on one occasion from epistaxis. The orbital swelling receded and the diplopia. disappeared so long as recumbency was maintained. The LIVERPOOL NORTHERN HOSPITAL. the carotid was mentioned to the advisability of A CASE OF INTRA-CRANIAL ANEURYSM SUCCESSFULLY patient, but he preferred going home. He remained away TREATED BY LIGATION OF THE COMMON from July 26th, 1888, to April 26th, 1889, when he returned CAROTID ARTERY ; REMARKS. with an aggravation of all the previous symptoms. The operation was now strongly urged upon him, and he was. (Under the care of Mr. CHAUNCY PUZEY.) transferred to the care of Mr. Puzey. INTRA-CRANIAL aneurysm of sufficient size to present Condition on admission into the Northern Hospital.symptoms permitting of correct diagnosis and the trial of There is a swelling in the left orbit about the size of & surgical measures to effect a cure is rarely met with, and Tangerine orange, the eyeball in the centre of it being much, this account of a case of the disease will repay careful protruded and congested, the cornea hazy, and at one point tendency to necrosis ; the eyelids are red and reading. The onset of an audible bruit immediately after showing cedematous. The whole swelling pulsates, and the pulsation fourteen months to the accident, before admission, appears controlled by pressure on the left common carotid; accurately define the duration of the disease, and the sym- can bevessels large (apparently veins) can be felt pulsating no 3 Med. Chir. Trans., vol. lix. pressing lightly on the swelling between the eye and the execute
ligaturing
I
369
’
upper part of the orbital cavity. A loud bruit can be heard all over the left side of the cranium, from the middle line as far back as the posterior parietal region; but it is loudest, in the supra-orbital and anterior temporal regions. The sound is of a loud "swishing" character, although the noise or patient describes it as resembling the boominghim from "thud" of machinery, which, he says, prevents sleeping, except when quite worn out by exhaustion. On May 5th Mr. Puzey ligatured the left common carotid artery above the omo-hyoid muscle. The operation was conducted with full antiseptic precautions, and the artery was tied with ’stout chromicised catgut ligature; the wound was closed with silver sutures, a thin horsehair drain being laid from end to end, and a small indiarubber tube passed into the deepest part of the wound. Pulsation ceaaed in the swelling as soon as the ligature As soon as the was tightened, and never reappeared. patient became sensible he exclaimed with delight that the noise had gone. However, on listening through the stethoscope over the eyebrow or near the root of the nose, a faint bruit, continuous, but accentuated with each systole, could be distinctly heard. Next day the dressings were changed and the horsehair drain was removed. On May 8th the dressings were again changed and some of the stitches removed. On the 10th the man had been moving his head about and had displaced the dressings, which were found soiled, and that night his temperature rose to 101’20. Next day there was some redness and swelling about the wound, and the man complained of slight paia in swallowing. It was evident tuat there was retention in the deep part of the wound. This was therefore reopened to some extent by probe and dressings forceps, and a small quantity of thick pus escaped. Next day all pain had gone and the temperature was normal, at which point it continued steady, except on June 2nd and 3rd, when it ran up again, probably on account of ffpcal accumulation in the lower bowel. The cornea had by this time given way, and the iris was adherent. A troublesome sinus, resulting from the reopening of the wound, caused him to remain in hospital for some weeks, although he was able to get up and walk about. He was sent to the Woolton Convalescent Hospital early in July, and returned to his home in Wales a few weeks later. On July 7tb, 1890, he wrote saying that the noise in his head had entirely gone, the swelling about his eye had completely disappeared, that he was quite comfortable in every way, and was actively engaged in his usual employment.
PGzEY.-In the article on "Orbital Walter Rivington, in Heath’s " Dictionary of Practical Surgery," it is stated that "beyond question the great majority of the traumatic cases have been instances of endo-cranial arterio-venous communication, due to wound or rupture of the internal carotid artery in the cavernous sinus." I believe that this case was an instance. There was, however, one point on which I could not satisfy myself-that was, as to the continuity of the bruit; if there was continuity, it was completely masked by the tremendous and prolonged "swish" during the systole. But I think that the remarkable dilatation and of the supra-orbital branches of the ophthalmic pulsation vein pointed almost conclusively to the nature of the affection. And, furthermore, the persistence of the bruit (as heard through the stethoscope) after the operation, long after the disappearance of the noise heard by the patient and of pulsation as felt by observers, seems to confirm that view of the case. Surely, if this had been a case of true aneurysm the bruit would havee ceased simultaneously with the notable pulsation. Although ligation of the common carotid is forcibly urged by Mr. Rivington as the best treatment, this is not the opinion held by some surgeons of eminence. Hence it seems desirable that cases bearing upon this point should be recorded. Some time ago my friend Mr. George Walker brought before the Ophthalmological Society a patient suffering from (apparently) a similar condition of affairs. He proposed to tie the common carotid, but was dissuaded from doing so by the adverse opinion of two well-known surgeons, who considered the case one of arterio-venous communication. This patient was accidentally cured in a very remarkable manner. He was squeezed and much frightened (to the extent of fainting) in a theatre crush one night, and next morning found that the noise in his head had ceased. Gradually the other symptoms disappeared,
Remarks by Mr. Aneurysm," by Mr.
and complete recovery took placed It appears probable that some fibrinous clot must have become partly displaced in the affected part during the excitement and struggling to which he was subjected; and so a cure was roughly brought about in the same manner as by the late Sir William Furgusson’s more delicate and deliberate method of "I inanipulation." But, as Mr. Walker observed, it is not advisable to trust to the chapter of accidents. Perhaps in the next similar case hemiplegia, or sudden death, might be the result. In my case, nothing could be more gratifying than the delight and comfort manifested by the patient from the time when he first regained consciousness, after the operation, up to the present. He came to see me some weeks ago (a year and a half after the operation), and there was nothing to be seen of the former trouble except a small leucoma occupying the lower quadrant of the cornea. The eye had regained its natural size and appearance, and the pupil was clear. But the sight was lost, no doubt from long-continued stretching and atrophy of the optic nerve,-surely an argument against delay in operation.
Medical Societies. ROYAL MEDICAL &
CHIRURGICAL SOCIETY.
Macrodactyly and other forms of Congenital Overgrowth. AN ordinary meeting of this Society was held on Feb. 10th,
the President, Mr, Timothy Holmes, in the chair. Sir GEORGE MURRAY HUMPHRY communicated a paper on Macrodactyly and some other forms of Congenital Overgrowth and their Relations to Tumours, of which the following is a brief abstract. An account was given of six specimens and casts of the affection in the museum of the University of Cambridge, and of nineteen cases published in various journals. The affection consisted in an overgrowth of all the tissues of the part-bones, ligaments, tendons, skin, and more particularly of the fat and connective tissuethese tissues usually presenting their normal characters. The overgrowth continued to proceed after birth, often at a rate exceeding that of the rest of the body, and so as to call for removal of the part. The hands and the feet were about equally liable, and the digits on the radial and tibial sides more than the others. In some cases the overgrowth showed a tendency to spread, more particularly along the sole. Now and then it was symmetrical, and occasionally it was associated with fatty growths in other parts. Reference was made to congenital overgrowths of like nature in lips, tongue, and face; and an analogy was drawn between these examples of intra-uterine insubordination to the laws of development and growth, and the growths or "tumours" of later life, all or nearly all of which-simple and malignant-were referable to an abnormal overgrowth of the normally existing tissues rather than to a starting into activity of latent embryonic germs. Mr. R. WILLIAMS found that the arguments which Sir George Humphry had used were almost identical with his own. Changes of growth and development which commenced before birth continued during the whole period of life. The force in action was of the kind known as "integrating force," and the failure of this was the cause of all abnormal growths. He referred to hypertrophy of the breast as another instance of the kinds which had been mentioned, for in it there was not only enlargement, but also a repetition of the normal structure. If growths could arise in the way described from normal structure, they were even more likely to do so from "tumour germs." Mr. MARMADUKE SHEILD was anxious to bring before the notice of the Society a class of cases which he believed had not as yet been described. It affected young adults, and was associated with flat and sweating feet. There was an enlargement of the great toe, and much pain and inconvenience were referred to the metatarso-phalangeal joint. The soft parts became very bulky, so that in an instance he exhibited the patient was discharged from the army because he could not pull his boots on. He had excised the joint, but found that both bone and cartilage presented simple overgrowth. He asked the opinion of the author as to the condition of molluscum fibrosum, where large flaps of skin 1
Ophthalmic Review,
vol.
vi.,
p.
209, 1887.
by pushing the intussusceptum out by pressure on ptoms of the condition were unusually well marked. Mr, the sheath, and partly by very gentle traction upon it. Puzey refers in his remarks to Mr. Rivington’s excellent It is very important that the parts should be well article on Orbital Aneurysms, and we find there mentioned in view when the swollen head of the tumour is being that in four traumatic cases, out of fourteen of which the returned, so that the amount of tension that is produced can post-mortem examination is given, there were arteriobe noted, and so that any laceration of the peritoneum, venous communications between the carotid and the cavershould it occur, may be detected and afterwards closed by nous sinus. Mr. Rivington refers to thirty-two cases of suture. I am convinced that in the majority of cases reduc- pulsating exophthalmos of traumatic origin, twenty-seven tion can be easily effected in the manner described, if the of which recovered and five died after ligature of the intussusception has not been strangulated for more than ten common carotid artery. " Of the twenty-seven patients or twelve hours ; but if strangulation has existed for eighteen who recovered after ligature, only seventeen were cured hours and upwards, reduction is likely to be difficult and of the aneurysmal affection of the orbit, additional will often be impossible. In the case above related the age methods being employed in the others. Ligature of the of the patient was nine months, and the intussusception common carotid is at present the most successful and satishad existed for about eighteen hours. In a successful case factory means of treating orbital aneurysm. The percentage which I recorded in 18753 the child was seven months old, of absolutely successful cases or cures would be about fiftyand the intussusception (which had apparently existed for five." We have recently referred to the high mortality met, fourteen days) had been strangulated for twelve hours. In with after ligature of the common carotid, and it is possibleboth, at the time the operation was performed, the infants that in this case the earlier compression of the vessel aided’ were in a condition of collapse ; the one was pale, his face in the efficient blood supply found after the application of was pinched, his pulse quick and feeble, and vomiting was the ligature. E. E-, aged thirty-seven, a farm labourer from North frequent; the other 6lay in his mother’s arms, vomiting every two or three minutes, with a pale shrunken face, Wales, was admitted into the hospital on May 2nd, 1889, half-closed eyes, a small and very rapid pulse, and shallow, and gave the following account of himself. He had always.
hurried respiration." Yet both recovered without a drawback of any kind, and were convalescent on the third day; both, that is to say, notwithstanding their serious condition, bore the operation perfectly well, and rallied immediately after it. In the case which I published in 1875 the operation was performed in a labourer’s cottage, with no antiseptic precautions. The intestines were for some minutes lying exposed outside the abdominal cavity, and the patient was subsequently nursed by its mother without skilled assistance. The facts observed in these two cases appear to constitute strong evidence that even young infants will bear the operation well. That failures have hitherto been frequent has been, I think, quite certainly due very largely to the circumstance that the operation has been delayed until the local conditions-swelling, inflammatory softening, and adhesions have precluded success. These conditions are not usually present in the first twelve or -
enjoyed good health until fourteen months ago, when he fell off a horse on to the left side of his head. He was semi. conscious for a day or two, the only thing he remembers) being that on the morning after the fall he noticed "anoiselike a steam-engine puffing in his head," just above his left, ear, and this has continued more or less ever since. Both eyes were swollen at that time, especially in the morning, the leftbeing the worse of the two. Four or five days after the accident he went to work, though the noise in his heacfj much troubled him. He was unable to see clearly unless he covered one eye. Six weeks after the accident he went. to the Liverpool Eye and Ear Infirmary, and remained thereunder the care of Mr. Edgar Browne. ]Jfr. Edgar Browne’s report.-E. E- was admitted on May 4th, 1888, his condition being as follows : Right eye: V. =t%, slightly myopic, with - 0-50 V. =’3!1, T. and appearance
normal; pupil active ; nystagmic
jerkings on
extreme
lateral deviation to either side; ophthalmoscope shows’ even the first eighteen hours. I ought, however, to mention shallow physiological pit. Left eye: V. =idem, slight, that in a case, under the care of Mr. Gay of Putney, in proptosis ; movements in all directions limited, pupil active, which I performed abdominal section about fifteen hours but rather le3s so than the other. Conjunctiva injected, (so far as could be ascertained) after the occurrence of the very large, tortuous, episcleral veins at the outer side; aful3 intussusception, the volvulus had become universally adhe- cushiony feeling on pressing eyelids. Pulsation of eyerent to its sheath, so that although the parts were well in ball distinctly felt on pressure. Ophthalmoscope showsview, and no inflammatory softening and only very limited marked physiological pit, with vessels crowded to one side,
swelling
were
present, it
was
impossible
to
accomplish
reduction. The possibility of this rapid formation of adhesions is an additional reason for early interference. I have lately examined the specimens in the museum of St. Bartholomew’s Hospital, with the view of ascertaining whether, when it is found that the head of the intussuseeption is so large and firm that it cannot be returned, it would i be possible with safety to divide the sheath at the seat of constriction, and then, having effected reduction, to close the wound in the sheath by suture. The point, however, is one which I think can only be determined by trials made in what may seem to be appropriate cases at the time of operation. Other cases in which abdominal section for intussusception in young infants has been successfully performed have, I believe, recently occurred. Their publication, I may perhaps be allowed to say, would be a valuable contribution to this important subject.
as in a glaucomatous disc, with pale halo, no pulsation of arteries could be produced even by firm pressure. There is a loud aneurysmal bruit on the left side of the head, loudest in the temporo-parietal region, immediately over the left ear, and extending forwards ; the sound becomes. fainter on approaching the vertex, again increasing towards the lower parietal region of the right side. It is stopped entirelv by moderate pressure on the left carotid. Diplopia. is marked, being due to the left eye, which is unable ta.
conjugate movements with its fellow, in consequence of orbital swelling. No implication of any motor or sensory nerve was observed, mental faculties unaffected. The diagnosis of intra. cranial aneurysm was made, and the treatment was-rest, full doses of iodide of potas sium, low diet, fluid restricted to one pint per diem, and digital pressure on the carotid. Steady improvement went, on for some weeks, interrupted once by the patient rising. Great relief from the noise resulted on one occasion from epistaxis. The orbital swelling receded and the diplopia. disappeared so long as recumbency was maintained. The LIVERPOOL NORTHERN HOSPITAL. the carotid was mentioned to the advisability of A CASE OF INTRA-CRANIAL ANEURYSM SUCCESSFULLY patient, but he preferred going home. He remained away TREATED BY LIGATION OF THE COMMON from July 26th, 1888, to April 26th, 1889, when he returned CAROTID ARTERY ; REMARKS. with an aggravation of all the previous symptoms. The operation was now strongly urged upon him, and he was. (Under the care of Mr. CHAUNCY PUZEY.) transferred to the care of Mr. Puzey. INTRA-CRANIAL aneurysm of sufficient size to present Condition on admission into the Northern Hospital.symptoms permitting of correct diagnosis and the trial of There is a swelling in the left orbit about the size of & surgical measures to effect a cure is rarely met with, and Tangerine orange, the eyeball in the centre of it being much, this account of a case of the disease will repay careful protruded and congested, the cornea hazy, and at one point tendency to necrosis ; the eyelids are red and reading. The onset of an audible bruit immediately after showing cedematous. The whole swelling pulsates, and the pulsation fourteen months to the accident, before admission, appears controlled by pressure on the left common carotid; accurately define the duration of the disease, and the sym- can bevessels large (apparently veins) can be felt pulsating no 3 Med. Chir. Trans., vol. lix. pressing lightly on the swelling between the eye and the execute
ligaturing
I
369
’
upper part of the orbital cavity. A loud bruit can be heard all over the left side of the cranium, from the middle line as far back as the posterior parietal region; but it is loudest, in the supra-orbital and anterior temporal regions. The sound is of a loud "swishing" character, although the noise or patient describes it as resembling the boominghim from "thud" of machinery, which, he says, prevents sleeping, except when quite worn out by exhaustion. On May 5th Mr. Puzey ligatured the left common carotid artery above the omo-hyoid muscle. The operation was conducted with full antiseptic precautions, and the artery was tied with ’stout chromicised catgut ligature; the wound was closed with silver sutures, a thin horsehair drain being laid from end to end, and a small indiarubber tube passed into the deepest part of the wound. Pulsation ceaaed in the swelling as soon as the ligature As soon as the was tightened, and never reappeared. patient became sensible he exclaimed with delight that the noise had gone. However, on listening through the stethoscope over the eyebrow or near the root of the nose, a faint bruit, continuous, but accentuated with each systole, could be distinctly heard. Next day the dressings were changed and the horsehair drain was removed. On May 8th the dressings were again changed and some of the stitches removed. On the 10th the man had been moving his head about and had displaced the dressings, which were found soiled, and that night his temperature rose to 101’20. Next day there was some redness and swelling about the wound, and the man complained of slight paia in swallowing. It was evident tuat there was retention in the deep part of the wound. This was therefore reopened to some extent by probe and dressings forceps, and a small quantity of thick pus escaped. Next day all pain had gone and the temperature was normal, at which point it continued steady, except on June 2nd and 3rd, when it ran up again, probably on account of ffpcal accumulation in the lower bowel. The cornea had by this time given way, and the iris was adherent. A troublesome sinus, resulting from the reopening of the wound, caused him to remain in hospital for some weeks, although he was able to get up and walk about. He was sent to the Woolton Convalescent Hospital early in July, and returned to his home in Wales a few weeks later. On July 7tb, 1890, he wrote saying that the noise in his head had entirely gone, the swelling about his eye had completely disappeared, that he was quite comfortable in every way, and was actively engaged in his usual employment.
PGzEY.-In the article on "Orbital Walter Rivington, in Heath’s " Dictionary of Practical Surgery," it is stated that "beyond question the great majority of the traumatic cases have been instances of endo-cranial arterio-venous communication, due to wound or rupture of the internal carotid artery in the cavernous sinus." I believe that this case was an instance. There was, however, one point on which I could not satisfy myself-that was, as to the continuity of the bruit; if there was continuity, it was completely masked by the tremendous and prolonged "swish" during the systole. But I think that the remarkable dilatation and of the supra-orbital branches of the ophthalmic pulsation vein pointed almost conclusively to the nature of the affection. And, furthermore, the persistence of the bruit (as heard through the stethoscope) after the operation, long after the disappearance of the noise heard by the patient and of pulsation as felt by observers, seems to confirm that view of the case. Surely, if this had been a case of true aneurysm the bruit would havee ceased simultaneously with the notable pulsation. Although ligation of the common carotid is forcibly urged by Mr. Rivington as the best treatment, this is not the opinion held by some surgeons of eminence. Hence it seems desirable that cases bearing upon this point should be recorded. Some time ago my friend Mr. George Walker brought before the Ophthalmological Society a patient suffering from (apparently) a similar condition of affairs. He proposed to tie the common carotid, but was dissuaded from doing so by the adverse opinion of two well-known surgeons, who considered the case one of arterio-venous communication. This patient was accidentally cured in a very remarkable manner. He was squeezed and much frightened (to the extent of fainting) in a theatre crush one night, and next morning found that the noise in his head had ceased. Gradually the other symptoms disappeared,
Remarks by Mr. Aneurysm," by Mr.
and complete recovery took placed It appears probable that some fibrinous clot must have become partly displaced in the affected part during the excitement and struggling to which he was subjected; and so a cure was roughly brought about in the same manner as by the late Sir William Furgusson’s more delicate and deliberate method of "I inanipulation." But, as Mr. Walker observed, it is not advisable to trust to the chapter of accidents. Perhaps in the next similar case hemiplegia, or sudden death, might be the result. In my case, nothing could be more gratifying than the delight and comfort manifested by the patient from the time when he first regained consciousness, after the operation, up to the present. He came to see me some weeks ago (a year and a half after the operation), and there was nothing to be seen of the former trouble except a small leucoma occupying the lower quadrant of the cornea. The eye had regained its natural size and appearance, and the pupil was clear. But the sight was lost, no doubt from long-continued stretching and atrophy of the optic nerve,-surely an argument against delay in operation.
Medical Societies. ROYAL MEDICAL &
CHIRURGICAL SOCIETY.
Macrodactyly and other forms of Congenital Overgrowth. AN ordinary meeting of this Society was held on Feb. 10th,
the President, Mr, Timothy Holmes, in the chair. Sir GEORGE MURRAY HUMPHRY communicated a paper on Macrodactyly and some other forms of Congenital Overgrowth and their Relations to Tumours, of which the following is a brief abstract. An account was given of six specimens and casts of the affection in the museum of the University of Cambridge, and of nineteen cases published in various journals. The affection consisted in an overgrowth of all the tissues of the part-bones, ligaments, tendons, skin, and more particularly of the fat and connective tissuethese tissues usually presenting their normal characters. The overgrowth continued to proceed after birth, often at a rate exceeding that of the rest of the body, and so as to call for removal of the part. The hands and the feet were about equally liable, and the digits on the radial and tibial sides more than the others. In some cases the overgrowth showed a tendency to spread, more particularly along the sole. Now and then it was symmetrical, and occasionally it was associated with fatty growths in other parts. Reference was made to congenital overgrowths of like nature in lips, tongue, and face; and an analogy was drawn between these examples of intra-uterine insubordination to the laws of development and growth, and the growths or "tumours" of later life, all or nearly all of which-simple and malignant-were referable to an abnormal overgrowth of the normally existing tissues rather than to a starting into activity of latent embryonic germs. Mr. R. WILLIAMS found that the arguments which Sir George Humphry had used were almost identical with his own. Changes of growth and development which commenced before birth continued during the whole period of life. The force in action was of the kind known as "integrating force," and the failure of this was the cause of all abnormal growths. He referred to hypertrophy of the breast as another instance of the kinds which had been mentioned, for in it there was not only enlargement, but also a repetition of the normal structure. If growths could arise in the way described from normal structure, they were even more likely to do so from "tumour germs." Mr. MARMADUKE SHEILD was anxious to bring before the notice of the Society a class of cases which he believed had not as yet been described. It affected young adults, and was associated with flat and sweating feet. There was an enlargement of the great toe, and much pain and inconvenience were referred to the metatarso-phalangeal joint. The soft parts became very bulky, so that in an instance he exhibited the patient was discharged from the army because he could not pull his boots on. He had excised the joint, but found that both bone and cartilage presented simple overgrowth. He asked the opinion of the author as to the condition of molluscum fibrosum, where large flaps of skin 1
Ophthalmic Review,
vol.
vi.,
p.
209, 1887.